Drop Foot With Posterior Tibialis Weakness Treated With Peroneus Longus Transfer in a Child: A Case Report.

CASE: An 8-year-old girl with a history of acute flaccid paralysis presented with chronic valgus drop foot causing tripping and falling. Traditionally surgical correction of this deformity is accomplished by transferring the posterior tibialis tendon to enhance dorsiflexion. The authors describe a new technique which transfers the peroneus longus tendon to the dorsum of the foot in a patient with weakness of the posterior tibialis muscle. The patient's drop foot and gait were improved at the 22-month follow-up. CONCLUSION: Successful transfer of the peroneus longus was accomplished with improved limb clearance during gait and coronal alignment in stance.

Thoracic outlet decompression surgery for Gilliatt-Sumner hand as a presentation of neurogenic thoracic outlet syndrome.

BACKGROUND: Chronic compression of the inferior trunk of the brachial plexus can result in severe pain and progressive atrophy and weakness of the musculature of the forearm and hand, known as Gilliatt-Sumner hand (GSH). The objective of treatment for these patients is to stop further atrophy and pain. Restoration of motor function has been thought to be seldom achieved. The aim of the present contemporary case series was to describe the diagnosis, treatment, and outcomes of surgery for GSH. METHODS: All patients referred between January 2017 and May 2021 with visible signs of a GSH were included. Visible GSH signs were defined as muscle atrophy of the abductor digiti minimi, abductor pollicis brevis, and/or interosseous musculature. All the patients had undergone additional electrodiagnostic (ED) assessments and high-resolution ultrasound (HRUS) studies. All the patients with a diagnosis of GSH had undergone thoracic outlet decompression (TOD) surgery using a transaxillary or supraclavicular approach. The outcomes were measured using the thoracic outlet syndrome disability scale, cervical brachial symptom questionnaire, and disability of the arm, shoulder, and hand scale scores and patient-reported outcomes of motor function, measured using a numerical rating scale (NRS). The standardized elevated arm stress test (sEAST) was used to assess the patients' motor function before and after TOD surgery. RESULTS: A total of 20 patients had been referred to our center with visible signs of a GSH. The clinical examination showed atrophy of the abductor digiti minimi, abductor pollicis brevis, and interosseous musculature in all 20 patients. The ED assessments showed plexopathy of the lower brachial plexus in all the patients. HRUS showed an indented inferior trunk of the brachial plexus (so-called wedge-sickle sign) in 18 patients (90%). Of the 20 patients, 17 had undergone TOD surgery (15 transaxillary TOD and 2 supraclavicular TOD). Three patients had refrained from surgery. The median follow-up interval was 15.0 months (interquartile range, 14.0 months). The thoracic outlet syndrome disability scale score had improved significantly (preoperatively: mean, 6.31; 95% confidence interval [CI], 5.49-7.13; postoperatively: mean, 4.25; 95% CI, 2.80-5.70; P = .026). The same improvement was seen for the cervical brachial symptom questionnaire scores (preoperatively: mean, 77.75; 95% CI, 66.63-88.87; postoperatively: mean, 42.65; 95% CI, 24.77-60.77; P = .001) and disability of the arm, shoulder, and hand scale scores (preoperatively: mean, 59.13; 95% CI, 51.49-66.77; postoperatively: mean, 40.96; 95% CI, 24.41-57.51; P = .032). The NRS score for muscle weakness and sEAST score showed no statistically significant differences before and after TOD for the whole group (mean preoperative NRS score for muscle weakness, 6.22; 95% CI, 4.31-8.14; mean postoperative NRS score for muscle weakness, 5.11; 95% CI, 3.25-6.97; P = .269). However, four patients (23.52%) had reported a ≥50% decrease in the NRS score for muscle weakness and a minimum increase of 20% in the total and average force using the sEAST. The NRS for numbness showed a statistically significant decrease for the whole group (preoperatively: mean, 5.67; 95% CI, 4.18-7.16; postoperatively: mean, 3.33; 95% CI, 1.37-5.29; P = .029). CONCLUSIONS: A combination of physical examination, ED assessments, and HRUS studies can differentiate GSH in the differential diagnosis. HRUS appears to have an advantage over ED studies in confirming GSH by visualization of compression of the brachial plexus. TOD surgery will stop the progressive muscle atrophy and significantly reduce neurogenic thoracic outlet syndrome complaints, and, in some patients, motor function will recover.

Effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions: A scoping review.

BACKGROUND: In the field of orthotics, the use of three-dimensional (3D) technology as an alternative to the conventional production process of orthoses is growing. PURPOSE: This scoping review aimed to systematically map and summarize studies assessing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions, and to identify knowledge gaps. METHODS: The Cochrane Library, PubMed, EMBASE, CINAHL, Web of Science, IEEE, and PEDro were searched for studies of any type of 3D-printed orthoses for traumatic and chronic hand conditions. Any outcome related to the effectiveness of 3D-printed orthoses was considered. Two reviewers selected eligible studies, charted data on study characteristics by impairment type, and critically appraised the studies, except for case reports/series. RESULTS: Seventeen studies were included: four randomized controlled trials, four uncontrolled trials, four case series and five case reports. Only three studies had a sample size >20. Impairments described were forearm fractures (n = 5), spasticity (n = 5), muscle weakness (n = 4), joint contractures (n = 2) and pain (n = 1). Four poor to fair quality studies on forearm fractures supported the effectiveness of 3D-printed orthoses on hand function, functionality, and satisfaction. One good quality study on spasticity demonstrated the effectiveness of 3D-printed orthoses on hand function. One poor quality pain study reported limited positive effects on satisfaction. Studies on muscle weakness and joint contractures showed no benefits. CONCLUSION: Current literature addressing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions consists primarily of small and poor methodological quality studies. There is a need for well-designed controlled trials including patient-related outcomes, production time and cost analyses.

Occipitopexy as a Fusionless Solution for Dropped Head Syndrome: A Case Report.

CASE: A 68-year-old woman suffered from an irradiation-induced dropped head syndrome (DHS). Fusion surgery was vehemently rejected by the patient. A new surgical method, avoiding fusion, was invented and performed to treat her DHS. This novel surgical technique of "occipitopexy"-a ligamentous fixation of the occiput to the upper thoracic spine-is described in detail. One year postoperatively, the patient was very satisfied, able to maintain a horizontal gaze, and rotate her head 20° to each side. CONCLUSION: This is the first report describing "occipitopexy" as an alternative to cervicothoracic fusion for patients with flexible DHS.

Systematic review of reversing pseudoparalysis of the shoulder due to massive, irreparable rotator cuff tears.

BACKGROUND: Correcting pseudoparalysis of the shoulder due to massive rotator cuff tear is challenging. The most reliable treatment for restoring active shoulder elevation is debatable. Therefore, the purpose of this systematic review was to evaluate the success of various treatment options for reversing pseudoparalysis due to massive rotator cuff tear. METHODS: A search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of the MEDLINE database, Cochrane database, Sportdiscus, and Google Scholar database for articles evaluating shoulder pseudoparalysis due to massive rotator cuff tears. RESULTS: Nine articles evaluating reverse total shoulder arthroplasty (RTSA), superior capsular reconstruction (SCR), and rehabilitation programs were included in the study. Though there was variability, the definition of pseudoparalysis was active forward elevation (AFE) less than 90° with preserved passive range of motion (ROM). Reversal of pseudoparalysis was defined as restoration of AFE greater than 90°. The overall rate of reversal of pseudoparalysis across studies was similar for RTSA (96% ± 17%) and SCR (94% ± 3%). However, there was a difference in average improvement in AFE for RTSA (56° ± 11°) and SCR (106° ± 20°). A progressive rehabilitation program described improvements in a single study with 82% reversal of pseudoparalysis. CONCLUSION: The available Level IV evidence suggests that RTSA and SCR reliably reverse pseudoparalysis in most patients with massive, irreparable rotator cuff tears. However, the dissimilar improvements in ROM suggest that a more consistent definition of pseudoparalysis is warranted. Future randomized controlled trials are needed to determine the best treatment approach for patients with massive irreparable rotator cuff tears.

Two Cases of Posterior Cerebral Artery P2 Segment Occlusion with Motor Weakness Improved by Acute Mechanical Thrombectomy.

BACKGROUND: Clinical evidence to support the use of mechanical thrombectomy (MT) for posterior cerebral artery P2 segment occlusion (P2O) has not been established, and hemiplegia due to P2O improved by MT to our knowledge has not yet been reported. We report 2 cases of P2O with hemiplegia improved by MT. CASE DESCRIPTION: In case 1, a 68-year-old man was admitted with right hemiplegia and dysesthesia (National Institutes of Health Stroke Scale score 14). Head magnetic resonance imaging showed acute ischemia in the left inferolateral thalamus and posterior limb of the internal capsule. Angiography showed left P2O, which was recanalized after MT. Hemiplegia improved immediately following recanalization, and modified Rankin Scale score at discharge was 0. In case 2, a 69-year-old man was admitted with left hemiplegia and dysesthesia (National Institutes of Health Stroke Scale score 8). Head magnetic resonance imaging showed acute ischemia in the right inferolateral thalamus and posterior limb of the internal capsule. Angiography showed right P2O, which was recanalized after MT, as in case 1. His symptoms resolved completely. CONCLUSIONS: P2O may cause severe motor deficit. In such cases, MT may contribute to safely improving patients' deficits.

Impact of Spinopelvic sagittal alignment on the surgical outcomes of dropped head syndrome: a multi-center study.

BACKGROUND: Most of the previous studies about the surgical treatment of dropped head syndrome (DHS) are small case series, and their primary outcome measures were cervical alignment parameters. Therefore, little is known about the associations between pre- and postoperative global sagittal alignment in the whole spine and the clinical outcomes of the surgical treatment of DHS. In this study, we investigated the surgical outcomes of DHS, including correction of cervical and global spinal sagittal alignment. METHODS: This study was a retrospective observational study. Fifteen patients with DHS who had undergone correction surgery were enrolled. Surgical outcomes, including complications and implant failures, were investigated. We assessed cervical alignment parameters as well as spinopelvic global alignment parameters, including pelvic incidence (PI), lumbar lordosis (LL), and C7-sacral sagittal vertical axis (SVA). We examined the changes in these parameters using pre- and posoperative whole spine lateral radiographs. The parameters were compared between the failure and nonfailure groups. RESULTS: Recurrence of sagittal imbalance and horizontal gaze difficulty was observed in 6 cases (40%). In all, 3 cases (20%) exhibited a distal junctional failure and required multiple surgeries with extension of fusion. Of all the radiographic parameters compared between the failure and nonfailure groups, significant differences were only observed in pre and postoperative SVA and PI-LL. CONCLUSIONS: Our results suggest that the global sagittal alignment parameters, including PI-LL and SVA, were different between the patients with failure and non failure, and these parameters might have notable impacts on surgical outcomes. Surgeons should consider PI-LL and SVA while determining the surgical course for patients with DHS.

Traumatic Arteriovenous Fistula Between Extracranial Middle Meningeal Artery and Petrosal Vein.

BACKGROUND: The incidence of traumatic arteriovenous fistula (TAVF) between the middle meningeal artery (MMA) and the petrosal vein (PV) is rare. Although TAVF has been reported involving the MMA several sinus and veins, this is the first incidence of a fistula involving the extracranial MMA and PV. CASE DESCRIPTION: We present a 47-year-old male with sudden onset of weakness of his right limb and speech difficulty a few hours before admission to our facility. He had a 6-month history of mild traumatic head injury. Initial computed tomography revealed midbrain hemorrhage while digital subtraction angiography revealed a TAVF of the left MMA. Enhanced magnetic resonance imaging, however, revealed communication between the MMA and PV. We treated the patient with coil embolization via the transarterial route. CONCLUSIONS: This is the first incidence of a fistula connecting the extracranial MMA and PV. We managed the patient with only coil embolization without any further neurologic deficits.

Profound Finger Extension Weakness 21 Years After a Traumatic Lumbar Spine Pseudomeningocele.

BACKGROUND: We present a case report of traumatic pseudomeningocele and a review of the literature and discussion of the neuro-cytoarchitecture to address the disproportionate weakness of extensor neurons seen in the case. CASE DESCRIPTION: A 42-year old man developed profound hand weakness 21 years after a lumbar spinal fracture. An examination revealed bilateral hand weakness affecting the extensors of the hands. Imaging studies revealed an extensive ventral epidural pseudomeningocele extending from the area of the lumbar spinal fracture to the cervical spine posteriorly displacing the spinal cord and the ventral motor roots. CONCLUSIONS: The patient was successfully treated with a subarachnoid-peritoneal shunt, which completely resolved the epidural pseudomeningocele and resulted in improvement but not resolution of his neurologic deficits.

The Recovery of Motor Strength after Posterior Percutaneous Endoscopic Cervical Foraminotomy and Discectomy.

OBJECTIVE: Cervical radiculopathy infrequently presents with motor weakness. Motor weakness was improved in >90% of patients after anterior cervical discectomy and fusion or posterior cervical foraminotomy. Posterior percutaneous endoscopic cervical foraminotomy and discectomy (PECF) is an alternative surgical technique, but the outcome of motor weakness has not been reported. Our objective was to demonstrate the longitudinal outcomes of motor weakness after PECF. METHODS: A retrospective review of 106 consecutive patients was performed. Preoperative motor weakness was graded as mild (IV/V strength) or severe (less than III/V strength). The patients visited the outpatient clinic at 1, 3, 6, and 12 months after surgery and yearly thereafter. Improvement was defined as an improved weakness of more than 1 grade, and normalization was defined as the recovery of complete motor strength. RESULTS: Motor weakness preoperatively presented in 76 of 106 (72%) patients (49%, mild weakness; 23%, severe weakness). After PECF, the weakness improved in 72 of 76 (95%) patients and normalized in 65 of 76 (86%) patients. In the patients with mild weakness, the normalization rates were 48%, 81%, 90%, and 96% at postoperative months 1, 3, 6, and 12, respectively. In the patients with severe weakness, the improvement rates were 50%, 71%, 83%, 88%, and 92%, and the normalization rates were 8%, 38%, 58%, 58%, and 63% at postoperative months 1, 3, 6, 12, and 24, respectively. CONCLUSIONS: Preoperative motor weakness was improved in 95% of the patients after PECF, but motor weakness was not normalized in 37% of the patients with severe weakness.

Treatment of Cervical Spondylotic Amyotrophy With Nerve Transfers.

Cervical spondylotic amyotrophy is characterized by severe, proximal upper extremity weakness including an inability to abduct the shoulder and flex the elbow. Treatment using both medical and surgical decompression approaches has produced variable results. This paper reports the use of nerve transfers (spinal accessory to suprascapular, flexor carpi ulnaris fascicle of ulnar to biceps motor branch, radial nerve branch to triceps to axillary) to restore shoulder and elbow function in a case of unilateral cervical spondylotic amyotrophy involving C5 and C6 myotomes. Evidence of regeneration was observed on electromyography as well as clinically at 5 months postoperatively. At 3 years after surgery, recovery of elbow flexion and shoulder abduction was Medical Research Council grade 4/5 with improved external rotation and considerably improved patient-rated Disabilities of the Arm, Shoulder and Hand scores. We propose that nerve transfers be considered along with other reconstruction modalities in the treatment of cervical spondylotic amyotrophy.

Spontaneous Repeated Disappearance and Recurrence of Multiple Spinal Intradural Arachnoid Cysts in a Child.

BACKGROUND: Spinal intradural arachnoid cysts are rare in the pediatric population. We present a rare case of intradural spinal arachnoid cysts that spontaneously and repeatedly disappeared and reoccurred. CASE DESCRIPTION: A 2-year-and-8-months-old boy presenting with lower extremity weakness was found to have spinal intradural arachnoid cysts in cervical and thoracolumbar regions at separate times. Although spontaneous disappearance of both lesions was observed, surgical treatment was finally performed for the symptomatic recurrent thoracolumbar lesion. CONCLUSIONS: To the best of our knowledge, this is the first report of spontaneously disappearing and recurring spinal arachnoid cysts.

Transfer of a Radial Nerve Branch to the Brachialis Nerve for Restoration of Elbow Flexion.

Nerve transfers for brachial plexus reconstruction and the treatment of peripheral nerve injury have demonstrated excellent clinical outcomes and may be superior to nerve grafting. Previously described nerve transfers for restoration of elbow flexion include the Oberlin (ulnar to musculocutaneous) and double fasicular (median to biceps and ulnar to brachialis) transfers. However, these transfers cannot be performed in patients with loss of elbow flexion and concomitant high median and ulnar nerve injury. Other transfers utilizing the thoracodorsal or intercostal nerves have been described; however, this requires sacrifice of the latissimus dorsi muscle or potential nerve donors for a free, functioning gracilis muscle transfer. The triceps lower medial head and anconeus motor branch is a frequently used nerve donor with minimal morbidity. As an alternative for this specific patient population, we report the transfer of the triceps lower medial head and anconeus motor branch to the brachialis nerve as an option to restore elbow flexion.

Radiologic features of dropped head syndrome in the overall sagittal alignment of the spine.

PURPOSE: Dropped head syndrome (DHS) is a rare clinical entity which is defined as a chin-on-chest deformity in the standing or sitting position, resulting from sagittal imbalance of the cervical region. The purpose of the present study was to clarify the radiologic features of DHS in the overall sagittal alignment of the spine. We also investigated the changes in sagittal alignment after correction surgery for DHS. METHODS: Twenty DHS patients [1 male and 19 female, with an average age of 78.9 years (range 59-88)] with a main complaint of horizontal gaze disorder were enrolled in this study. Spino-pelvic lateral radiographs in the free-standing clavicle position were taken of all patients. Parameters such as sagittal vertical axis (SVA), C2-7 angle, clivo-axial angle (CAA), C2-7 SVA, T1 slope, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured, and the radiologic features of DHS in the overall sagittal alignment of the spino-pelvis were investigated. Eight patients underwent correction surgery, and the parameter changes between pre- and post-operative radiographs were also examined. RESULTS: DHS appeared to have two distinct types: SVA+ and SVA-. Seven of 20 cases were SVA+, and 13 were SVA-. The radiologic parameters in which we found statistically significant differences between the groups were: 80.2 ± 68 and -44.5 ± 40 (SVA), 42.1 ± 16.8 and 18.4 ± 11.4 (T1 slope), and 21.1 ± 19.2 and 44.2 ± 19.8 (LL) in SVA+ and SVA-, respectively. After surgical intervention, T1 slope and LL appeared to approach normal in the SVA- group, because compensation at downward spine was no longer necessary. In SVA+ group, although the patients gained horizontal gaze after surgery, abnormality of the sagittal alignment in the whole spine remained, because compensation in the thoracic and lumbar spine was still insufficient. CONCLUSIONS: The present study has indicated that radiologic feature of DHS in the sagittal alignment of the overall spino-pelvis can be categorized into two types: SVA+ and SVA-.

A Confirmed Case in the United Kingdom of Hirayama Disease in a Young White Male Presenting with Hand Weakness.

BACKGROUND: We present the first reported case of Hirayama disease in the United Kingdom. A literature review of Hirayama disease in the Western literature shows that this case is unique in being the first in the United Kingdom, constituting one of only a few cases in Europe with supporting magnetic resonance imaging and reported treatment outcome. CASE DESCRIPTION: Our patient was a young Caucasian male who presented with progressive bilateral hand weakness, had confirmatory magnetic resonance imaging findings of Hirayama disease, and experienced improvement of symptoms with cervical collar immobilization. CONCLUSIONS: This case lends further evidence to the flexion-induced myelopathy theory of Hirayama disease and supports the findings of other studies in which avoidance of neck flexion and cervical immobilization helped to attenuate disease progression in this patient group.

Correcting myogenic ptosis accompanying extraocular muscle weakness: The "Bobby Pin" procedure.

This article evaluates the "Bobby Pin" procedure in the correction of myogenic ptosis accompanying extraocular muscle weakness. We retrospectively reviewed 26 eyelids of 13 patients who underwent "Bobby Pin" procedure for myogenic ptosis accompanying extraocular muscle weakness. We evaluated the patients' clinical features such as age, etiology of ptosis, symptoms, standard ptosis measurements, associated systemic diseases, additional ophthalmic conditions, complications, and recurrence. Etiology of myogenic ptosis and extraocular muscle weakness was oculopharyngeal dystrophy in 4 (31%) patients, chronic progressive external ophthalmoplegia in 4 (31%) patients, myotonic dystrophy in 2 (23%) patients, and idiopathic in 3 (15%) patients. The mean levator function was approximately 5 mm pre- and post-operatively (range 1 to 12 mm). The mean margin-to-reflex distance 1 increased from -1.1 mm (below the light reflex) pre-operatively to +0.4 mm (above the light reflex) post-operatively. After a mean follow-up of 40 months, only 1 (8%) patient experienced ptosis recurrence. Upper eyelids were symmetric in both contour and height in all patients. Mild superficial keratopathy involving less than 10% of cornea was observed in 4 (31%) patients. The "Bobby Pin" procedure is an effective and long-lasting treatment option for correcting acquired ptosis accompanying extraocular muscle weakness. The procedure is safe, simple, easily learned, time- and cost-effective, and does not require any expensive equipment.

Shoulder arthroplasty for sequelae of poliomyelitis.

BACKGROUND: Polio infection can often lead to orthopedic complications such as arthritis, osteoporosis, muscle weakness, skeletal deformation, and chronic instability of the joints. The purpose of this study was to assess the outcomes and associated complications of arthroplasty in shoulders with sequelae of poliomyelitis. METHODS: Seven patients (average age, 70 years) were treated between 1976 and 2013 with shoulder arthroplasty for the sequelae of polio. One patient underwent reverse shoulder arthroplasty, 2 had a hemiarthroplasty, and 4 had total shoulder arthroplasty. Average follow-up was 87 months. Outcome measures included pain, range of motion, and postoperative modified Neer ratings. RESULTS: Overall pain scores improved from 5 to 1.6 points (on a 5-point scale) after shoulder arthroplasty. Six shoulders had no or mild pain at latest follow-up, and 6 shoulders rated the result as much better or better. Mean shoulder elevation improved from 72° to 129°, and external rotation improved from 11° to 56°. Average strength in elevation decreased from 3.9 to 3.4 postoperatively, and external rotation strength decreased from 3.9 to 3.3. This, however, did not reach significance. Evidence of muscle imbalance with radiographic instability was found in 4 shoulders that demonstrated superior subluxation, anterior subluxation, or both. This remained asymptomatic. No shoulder required revision or reoperation. CONCLUSIONS: Shoulder arthroplasty provides significant pain relief and improved motion in patients with sequelae of poliomyelitis. Muscle weakness may be responsible for postoperative instability, and careful selection of the patient with good upper extremity muscles must be made.